Articles

Shared Savings Model Risk in the MSSP Program

The Centers for Medicare and Medicaid Services (CMS) introduced the Medicare Shared Savings Program (MSSP) for accountable care organizations (ACOs) as part of the Affordable Care Act. Participating ACOs accept risk for the financial outcomes of their assigned populations and share in gains (and, depending on the ACO model, losses) when these are generated. Payers and providers who negotiate value-based contracts need to be aware of and account for model risk in their contracts, particularly as the sizes of populations under management become smaller.

Payment Accuracy in Value-Based Care Contracts

Reimbursement for health care services is transferring more risk away from payers and toward health care providers in the form of Alternative Payment Models (APMs), also known as Value-Based Care (VBC) models. VBC models cover a wide variety of forms but all include guarantees by providers of services to improve quality of care and/or reduce cost.

The Management of Cardiometabolic Syndrome

Newtopia case study shows weight loss is a key factor

Modeling the Cost Effectiveness of VCTE for FLD

Modeling the Cost Effectiveness of VCTE for Fatty Liver Disease (FLD) In a General Population Incorporating Device Costs

Comparing Model Error Between a Standard Risk Adjustment Model and a Disease-Specific Risk Adjustment Model

Disease-specific health care interventions and programs are often evaluated with standard risk adjustment models or using more simplistic differences-in-differences approaches that are not customized for the target population. Using models specifically constructed for a target health condition population reduces the magnitude of the model error.

Strategies to Help Manage the Impact of COVID-19 on Elective Surgeries

Using data to help health plans and employers plan ahead, control costs and improve quality

Understanding the impact of five major determinants of health (genetics, biology, behavior, psychology, society/environment) on type 2 diabetes in U.S. Hispanic/Latino families: Mil Familias - a cohort study

A study to determine the influence of the 5 major determinants of human health (genetics, biology, behavior, psychology, society/environment) on the burden of T2D for Latino families

Effects of a Population Health Community-Based Palliative Care Program on Cost and Utilization

An evaluation of utilization and cost outcomes for a community-based palliative care program provided by nurses and social workers.

Impact of Cost on the Safety of Cancer Pharmaceuticals

A chapter, Impact of cost on the safety of cancer pharmaceuticals, by Fitzner and Oteng Mensah in a recent book, Cancer Policy: Pharmaceutical Safety, aims to inform readers about the economics associated with the interplay between safety, costs of cancer treatment, and outcomes of cancer care.

Racial and Ethnic Disparities in the Burden and Cost of Diabetes for US Medicare Beneficiaries

An examination of the burden and cost of diabetes among fee-for-service Medicare beneficiaries

Public Health: Actuaries Weighing in on Healthy People 2030

Healthy People 2030’s vision is a society in which all people achieve their full potential for health and well-being across the life span. The framework outlines foundational principles, a plan of action and goals that are admirable.

Integrating Claims-Based and Survey-Based Data to Estimate Program Savings

An innovative approach to evaluating overlapping medical intervention programs

Public Health: The New Frontier

The overarching objective of the task force is twofold: first, to educate actuaries on the importance of public health and how it can inform and affect our work as actuaries—we call this the “inward” focus; and second, to open channels to enable actuaries to contribute to public health efforts—we call this the “outward” focus.

Safety of Cancer Therapies: At What Cost?

The Choices People Make (and Their Implications for Private Exchanges)

Choice overload - the concept that individuals struggle to make a good decision, or even any decision, when presented with too much choice - is a well-researched phenomenon in behavioral economics, and we would expect to see this in health plan decisions.

Testing Alternative Regression Frameworks for Predictive Modeling of Health Care Costs

Published by The North American Actuarial Journal

Economics of Malignant Gliomas: A Critical Review

A review to examine costs to patients with malignant glioma and their families, payers, and society.

Measuring Healthcare Efficiency

From The North American Actuarial Journal

Impact of HIV-specialized pharmacies on adherence to medications for comorbid conditions

Medication Days' Supply, Adherence, Wastage, and Cost Among Chronic Patients in Medicaid

A study conducted to determine whether 90- day refills at community pharmacies could improve adherence, minimize wastage, and control costs

Mining Health Claims Data for Assessing Patient Risk

From the book, Data Mining: Foundations and Intelligent Paradigms, comes a chapter on applying data mining techniques to quantify patient risk

Assessing the Value of Diabetes Education

Measuring the financial impact of diabetes self-management education, published by The Diabetes Educator

A Comparative Analysis Of Chronic And Nonchronic Insured Commercial Member Cost Trends

Chronic and nonchronic cost trends between 1999 and 2002 published by The North American Actuarial Journal

Testing Actuarial Methods for Evaluating Disease Management Savings Outcomes

Measuring cost savings from a 2 year DM program, published by the Society of Actuaries (SOA)